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US20070093894A1 - Incorporation of antimicrobial combinations onto devices to reduce infection - Google Patents

Incorporation of antimicrobial combinations onto devices to reduce infection Download PDF

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Publication number
US20070093894A1
US20070093894A1 US11/586,407 US58640706A US2007093894A1 US 20070093894 A1 US20070093894 A1 US 20070093894A1 US 58640706 A US58640706 A US 58640706A US 2007093894 A1 US2007093894 A1 US 2007093894A1
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Prior art keywords
combination
medical device
bactericidal
bacteriostatic
agent
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US11/586,407
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English (en)
Inventor
Rabih Darouiche
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Baylor College of Medicine
US Department of Health and Human Services
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Baylor College of Medicine
US Department of Health and Human Services
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Priority to US11/586,407 priority Critical patent/US20070093894A1/en
Assigned to BAYLOR COLLEGE OF MEDICINE reassignment BAYLOR COLLEGE OF MEDICINE ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: DAROUICHE, RABIH O.
Publication of US20070093894A1 publication Critical patent/US20070093894A1/en
Abandoned legal-status Critical Current

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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
    • A61L31/00—Materials for other surgical articles, e.g. stents, stent-grafts, shunts, surgical drapes, guide wires, materials for adhesion prevention, occluding devices, surgical gloves, tissue fixation devices
    • A61L31/14—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
    • A61L31/16—Biologically active materials, e.g. therapeutic substances
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
    • A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
    • A61L27/50—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
    • A61L27/54—Biologically active materials, e.g. therapeutic substances
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
    • A61L29/00—Materials for catheters, medical tubing, cannulae, or endoscopes or for coating catheters
    • A61L29/14—Materials characterised by their function or physical properties, e.g. lubricating compositions
    • A61L29/16—Biologically active materials, e.g. therapeutic substances
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
    • A61L2300/00—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices
    • A61L2300/40—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices characterised by a specific therapeutic activity or mode of action
    • A61L2300/404—Biocides, antimicrobial agents, antiseptic agents

Definitions

  • This invention relates to the field of medicine. More particularly, it relates to medical devices and the combination of antibiotic compositions to coat and/or flush medical devices to decrease or reduce microbial infections and/or growth.
  • a known method of coating the devices is to first apply or absorb to the surface of the medical device a layer of tridodecylmethyl ammonium chloride (TDMAC) surfacant followed by an antiobiotic coating layer, see e.g. U.S. Pat. No. 6,719,991.
  • TDMAC tridodecylmethyl ammonium chloride
  • Another successful coating method is impregnation of an antimicrobial agent.
  • the antimicrobial agent penetrates and is incorporated in the exposed surfaces.
  • the antimicrobial composition is formed by dissolving an antimicrobial agent in an organic solvent, adding a penetrating agent, and adding an alkalinizing agent to the composition. See, e.g., U.S. Pat. No. 5,902,283 and U.S. Pat. No. 5,624,704.
  • a further method known to coat the surface of medical devices with antiobiotics involves first coating the selected surfaces with benzalkonium chloride followed by ionic bonding of the antiobiotic composition. See, e.g., Solomon, D. D. and Sherertz, R. J., J. Controlled Release, 6:343-352 (1987) and U.S. Pat. No. 4,442,133.
  • U.S. Pat. Nos. 5,624,704 and 5,902,283 disclose medical devices and methods for impregnating medical implants with antimicrobial agents so that the antimicrobial penetrates the material of the implants.
  • U.S. Pat. Nos. 5,756,145 and 5,853,745 disclose durable antimicrobial coatings for implants, such as orthopedic implants, and methods of coating them.
  • U.S. Pat. No. 5,688,516 describes compositions and methods of employing compositions to flush and coat medical devices, in which the compositions include combinations of a chelating agent, anticoagulant or antithrombotic agent with a non-glycopeptide antimicrobial agent.
  • the present invention is the first to utilize bacteriostatic and bactericidial antimicrobial compositions in conjunction to reduce putative colonization of a medical device by either coating the medical device or by providing the medium necessary to flush the medical device. It is envisaged that this invention reduces the infection rates related to microbial growth enough that the time a medical device remains implanted inside a patient is increased, thus reducing the medical expenses incurred by patients requiring the medical device. Complications related to growth of biolfim, a by product of excessive microbial proliferation commonly found on the surfaces of medical device, is also potentially reduced from effective flushing of the medical device, thus minimizing microbial related complications.
  • the present invention relates to coated medical devices, kits to coat medical devices and methods of coating such medical devices.
  • This invention delineates a novel method wherein a medical device is either flushed or coated with a unique combination of bacteriostatic and bactericidal agents.
  • the combination of bacteriostatic and bactericidal agents reduce, abrogate, or minimize microbial growth and or colonization when compared to uncoated or non-flushed medical devices.
  • Reduction, abrogation, or minimization of microbial growth can be attributed to the combination of the bacteriostatic and bacteriocidal agents acting synergistically and/or additively when used in an effective concentration such that the concentration is effective to reduce the growth of colonization of the microbes by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100% or any range therebetween.
  • An embodiment of the present invention is a method for coating a medical device comprising the steps of applying to at least a portion of the medical device, a bactericidal coating layer, wherein the bactericidal coating layer comprises a bactericidal agent; and applying to at least a portion of the surface of the medical device, a bacteriostatic coating, wherein the bacteriostatic coating layer comprises a bacteriostatic agent wherein the combination of the bactericidal and bacteriostatic agents are in an effective concentration to inhibit growth of microbial organisms relative to an uncoated medical device.
  • the bacteriostatic coating layer and the bactericidal coating layer may be applied simultaneously or consecutively. In other words, the bacteriostatic agent and the bactericidal agents may be combined in the same solution prior to coating the medial device or the agents are applied in layers on the medical device.
  • the bactericidal agent includes, but is not limited to aminoglycosides, penicillins, cephalosporins, carbapenems, glycopeptides, rifamycins, quinolones, fusidic acid, sulfonamides, streptogramins, lipopeptides, and combinations thereof.
  • the bacteriostatic agent includes, but is not limited to tetracyclines, macrolides, ketolides, chloramphenicols, oxazolidinones, lincosamindes, and combinations thereof.
  • a further embodiment is that the medical device is implanted into a subject at risk for infection, wherein the medical device is coated with a composition comprising a bactericidal agent and a bacteriostatic agent.
  • An embodiment of this invention is that it reduces colonization of gram positive bacteria, gram negative bacteria, fungi, and mycobacterium.
  • a further embodiment of this invention is that it reduces microbial growth not only on medical devices that are coated, but in flushing both coated and uncoated medical devices.
  • Another embodiment of this invention is that it has coated on one or more of its surfaces or at least on a portion of the surface an antibiotic composition comprising a combination of an aminoglycoside based drug and a tetracycline based drug, the combination coated is in an amount effective to inhibit microbial growth.
  • the combination of the bactericidal agent and bacteriostatic agent comprises a kit not only used for coating medical devices, but also for flushing the medical devices.
  • the kit contains a combination of an aminoglycoside and tetracycline based drug.
  • microbe(s) or “microbial organism” as used herein is defined as a microscopic organism such as bacteria, fungi, microscopic algae, protozoa, and viruses unable to be seen by the naked eye.
  • bactericidal as used herein is defined as an antimicrobial agent that: (a) is known by those of skill in the art to kill organisms in bacterial suspensions when used in concentrations that are equivalent to the serum concentrations that are clinically achieved in humans during systemic administration of the antimicrobial agent; and (b) is applied according to this invention (via coating or catheter lock/flush solution) to the surfaces of the medical devices in such a way that the total amount of each antimicrobial agent applied to the surfaces of the whole device does not exceed a daily systemic dose of that antimicrobial agent as an antimicrobial agent used to kill microbes.
  • bacteriostatic as used herein is defined as an antimicrobial agent that (a) is known by those of skill in the art to inhibit the growth of organisms in bacterial suspensions when used in concentrations that are equivalent to the usual serum concentrations that are achieved in humans during systemic administration of the antimicrobial agent; and (b) is applied according to this invention (via coating or catheter lock/flush solution) to the surfaces of the medical devices in such a way that the total amount of each antimicrobial agent applied to the surfaces of the whole device does not exceed a daily systemic dose of that antimicrobial agent used to inhibit growth but not kill microbes.
  • antibiotics as used herein is defined as a substance that inhibits the growth of microorganisms without damage to the host.
  • the antibiotic may inhibit cell wall synthesis, protein synthesis, nucleic acid synthesis, or alter cell membrane function.
  • the classes of antibiotics used may fall under two categories, bactericidal and bacteriostatic.
  • Bactericidal antibiotics include those from the group consisting of aminoglycosides, penicillins, cephalosporins, carbapenems, glycopeptides, rifamycins, quinolones, fusidic acid, sulfonamides, streptogramins, and lipopeptides.
  • Bacteriostatic antibiotics include those from the group consisting of tetracyclines, macrolides, ketolides, chloramphenicols, oxazolidinones, and lincosamindes.
  • bactericidal agents include, but are not limited to, kanamycin, gentamicin, tobramycin, netilmicin, sisomicin, amikacin, ampicillin, amoxicillin, cloxacillin, dicloxacillin, ticarcillin, indanyl carbenicillin, azlocillin, mezlocillin, nafcillin, oxacillin, piperacillin, cefazolin, cephalothin, cephapirin, cephradine, cefamandole, cefonicid, cefuroxime, cefmetazole, cefotetan, cefoxitin, cefotaxime, cefoperazone, ceftazidine, ceftizoxime,
  • bacteriostatic agents include, but are not limited to, oxytetracycline, demeclocycline, doxycycline, minocycline, tigecycline, erythromycin, clarithromycin, azithromycin, spiramycin, telithromycin, linezolid, eperezolid, clindamycin, and lincomycin.
  • coating as used herein is defined as a layer of material covering a medical device.
  • the coating can be applied to the surface or impregnated within the material of the implant.
  • the term “effective concentration” means that a sufficient amount of antimicrobial agent is added to decrease, reduce, abrogate, prevent, or inhibit the growth of bacteria and/or fungal organisms. The amount will vary for each compound and upon known factors such as pharmaceutical characteristics; the type of medical device; age, sex, health and weight of the recipient; and the use and length of use. It is within the skilled artisan's ability to relatively easily determine an effective concentration for each compound.
  • additive as used herein is defined as the additive antimicrobial effect when two antagonistic drugs are combined, enhancing the effect of the individual drugs in a linear manner when used together.
  • Gram-negative bacteria or “gram-negative bacterium” as used herein is defined as bacterium which have been classified by the Gram stain as having a red stain. Gram-negative bacteria have thin walled cell membranes consisting of a single layer of peptidoglycan and an outer layer of lipopolysacchacide, lipoprotein, and phospholipid.
  • Exemplary organisms include, but are not limited to, Enterobacteriacea consisting of Escherichia, Shigella, Edwardsiella, Salmonella, Citrobacter, Klebsiella, Enterobacter, Hafnia, Serratia, Proteus, Morganella, Providencia, Yersinia, Erwinia, Buttlauxella, Cedecea, Ewingella, Kluyvera, Tatumella and Rahnella.
  • exemplary gram-negative organisms not in the family Enterobacteriacea include, but are not limited to, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia, Cepacia, Gardenerella, Vaginalis, and Acinetobacter species.
  • Gram-positive bacteria or “gram-positive bacterium” as used herein refers to bacteria, which have been classified using the Gram stain as having a blue stain. Gram-positive bacteria have a thick cell membrane consisting of multiple layers of peptidoglycan and an outside layer of teichoic acid. Exemplary organisms include, but are not limited to, Staphylococcus aureus, coagulase-negative staphylococci, streptococci, enterococci, corynebacteria, and Bacillus species.
  • medical device refers to any material, natural or artificial that is inserted into a mammal.
  • Particular medical devices especially suited for application of the antimicrobial combinations of this invention include, but are not limited to, insertable central venous catheters, dialysis catheters, tunneled central venous catheters, peripheral venous catheters, percutaneously inserted central venous catheters, peripherally inserted central catheters (PICC), arterial catheters, pulmonary artery Swan-Ganz catheters, vascular catheter ports, wound drain tubes, hydrocephalus shunts, peritoneal dialysis catheters, defibrillators, pace-maker systems, artificial urinary sphincters, joint prostheses or replacements, urinary dilators, urinary devices, tissue bonding devices, penile prostheses, hernia mesh, ventricular catheter, ventricular shunts, urinary incontinence devices, bowel incontinence devices, vascular grafts, drug delivery systems (including pumps, generators,
  • Medical devices also include any device which may be inserted or implanted into a human being or other animal, or placed at the insertion or implantation site such as the skin near the insertion or implantation site, and which include at least one surface which is susceptible to colonization by microbes.
  • subject is taken to mean any mammalian subject to which the composition/medical device is administered.
  • a mammalian subject includes, but is not limited to humans, monkeys, horses, pigs, cows, dogs, cats, rats and mice.
  • the methods of the present invention are employed to treat a human subject.
  • the subject may or may not be cognizant of their disease state or potential disease state and may or may not be aware that they are need of treatment (therapeutic treatment or prophylactic treatment).
  • preventing is taken to mean the act of minimizing, inhibiting, impeding, and/or circumventing the growth of microbes, as previously defined, on at least one surface or at least a portion of one surface of an indwelling medical device, those of which are enumerated above.
  • inhibiting or “reducing” as used herein, is taken to mean the act of limiting the growth of microbes, as previously defined, on at least one surface or at least a portion of one surface of an indwelling medical device
  • This invention describes for the first time the use of a bacteriostatic and bactericidal agent used for coating and/or flushing medical devices.
  • the unique aspect of this invention is centered around the combination of two otherwise antagonistic antibiotic agents that wouldn't otherwise have been surmised to work in conjunction to reduce microbial colonization.
  • This invention reduces infection rates by reducing putative colonization of a medical device by either coating the medical device or by providing the medium necessary to flush the medical device.
  • the reduction in infection increases the time a medical device remains implanted inside a patient, reducing the medical expenses incurred by patients requiring the medical device.
  • the reduction in infection from effective flushing of the medical device prevents microbial related complications.
  • the combination of bacteriostatic and bactericidal agents reduce, inhibit, abrogate, or minimize microbial growth and or colonization when compared to uncoated or non-flushed medical devices. Reduction, abrogation, or minimization of microbial growth can be attributed to the combination of the bacteriostatic and bacteriocidal agents acting synergistically and/or additively when used in an effective concentration such that the concentration is effective to reduce the growth of colonization of the microbes by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100% or any range therebetween.
  • Exemplary medical devices include, but are not limited to, insertable central venous catheters, dialysis catheters, tunneled central venous catheters, peripheral venous catheters, percutaneously inserted central venous catheters, peripherally inserted central catheters (PICC), arterial catheters, pulmonary artery Swan-Ganz catheters, vascular catheter ports, wound drain tubes, hydrocephalus shunts, peritoneal dialysis catheters, defibrillators, pace-maker systems, artificial urinary sphincters, joint prostheses or replacements, urinary dilators, urinary devices, tissue bonding devices, penile prostheses, hernia mesh, ventricular catheter, ventricular shunts, urinary incontinence devices, bowel incontinence devices, vascular grafts, drug delivery systems (including pumps, generators, tubings, catheters, sensors, etc), fracture fixation devices, nervous system stimulation devices, bilary stents, nephromty catheter, bladder catheter, epiderma
  • Medical devices also include any device which may be inserted or implanted into a human being or other animal, or placed at the insertion or implantation site such as the skin near the insertion or implantation site, and which include at least one surface which is susceptible to colonization by microbes.
  • the steps involved in the coating the medical device of the present invention comprises applying to at least a portion of the medical device, a bactericidal coating layer, wherein the bactericidal coating layer comprises a bactericidal agent; and applying to at least a portion of the surface of the medical device, a bacteriostatic coating, wherein the bacteriostatic coating layer comprises a bacteriostatic agent wherein the combination of the bactericidal and bacteriostatic agents are in an effective concentration to inhibit growth of microbial organisms relative to an uncoated medical device.
  • coating at least a portion of the medical device wherein a portion is herein designated as a part, whole, or any designation in between these two boundaries. At least a portion implies coverage of the medical device in such a way that the entire medical device is eventually coated, but since the present invention uses the combination of two disparate antimicrobial agents, one bacteriostatic, the other bactericidal, there is a mixed distribution of the coating/impregnation solution on the surface of the medical device, specific in part to the intended clinical purpose of the medical device, the duration of the medical devices implantation, and other various parameters used in determining the appropriate mixture of bacteriostatic and bactericidal agents so that effective antimicrobial activity is achieved.
  • coating at least a portion of a medical device can include coating at least 1%, at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90 % or at least 100% of the medical device, or any range there between.
  • coating a portion of a medical device comprises coating at least 5% to at least a 100% of the device.
  • the medical devices that are amenable to impregnation by the antimicrobial combinations are generally comprised of a non-metallic or metallic material such as thermoplastic or polymeric materials.
  • a non-metallic or metallic material such as thermoplastic or polymeric materials.
  • materials are rubber, plastic, polyethylene, polyurethane, silicone, Gortex (polytetrafluoroethylene), Dacron (polyethylene tetraphihalate), polyvinyl chloride, Teflon (polytetrafluoroethylene), latex, elastomers, nylon and Dacron sealed with gelatin, collagen or albumin.
  • metallic materials include, but are not limited to, tivanium, titanium, and stainless steel.
  • Bioabsorbable polymers may also be amenable to coating.
  • the bioabsorbable polymers aid in orthopedic situations where the financial and physical cost of surgery to remove a medical device is too high and inconvenient.
  • each antimicrobial agent used to coat the medical device varies to some extent, but is at least a sufficient amount to form an effective concentration to inhibit the growth of microbial organisms.
  • the dual combination of the bactericidal and bacteriostatic antimicrobial agents are dispersed through the surface of the medical device.
  • the amount of each antimicrobial agent used to impregnate the medical device varies to some extent, but is in at least in an effective concentration to inhibit the growth of microbial organisms.
  • the antimicrobial agents can be applied to the medical device in a variety of methods. Exemplary application methods include, but are not limited to, spraying, painting, dipping, sponging, atomizing, smearing, impregnating and spreading.
  • the step of forming an antimicrobial composition may also include the step of adding an alkalinizing agent to the composition in order to enhance the reactivity of the material of the medical implant, as outlined in U.S. Pat. No. 5,902,283, herein incorporated in its entirety by reference.
  • the antimicrobial composition is heated to a temperature between about 30° C. and 70° C. prior to applying the composition to the medical implant to increase the adherence of the antimicrobial agent to the medical implant material.
  • the impregnated implant is preferably rinsed with a liquid and milked to remove excess granular deposits and ensure uniform color of the impregnated implant.
  • the antimicrobial composition may be applied to the medical implant by dipping the implant into the antimicrobial composition for a period of between 15 and 120 minutes, and then removing the impregnated implant from the composition.
  • the implant is dipped in the composition for a period of approximately 60 minutes.
  • the method of the present invention preferably comprises a single step of applying both antimicrobial compositions to the surfaces of a medical device.
  • both antimicrobial agents can be applied together in a single step.
  • the method of the application of the antimicrobial agents can vary and should not be limited to the described methods.
  • a skilled artisan recognizes that the order of the application of the compositions of both antimicrobial drugs is not relevant and can vary for any given application to a medical device
  • Another preferred embodiment of the present invention is directed to a medical implant having an antimicrobial layer and a protective layer, and a method for coating such an implant with an antimicrobial layer and a protective layer as delineated in U.S. Pat. No. 5,756,145, herein incorporated in its entirety as a reference.
  • the protective layer slows the leaching of antimicrobial agents from the surface of the implant and is resilient to resist sloughing of the antimicrobial agents during implantation.
  • the protective layer can also protect certain photosensitive antimicrobial agents from exposure to light or air. For instance, some antimicrobial agents, such as methylisothiazolone, are regarded as photosensitive.
  • the protective coating layer can be a single layer. It is either a durable coating layer or a resilient coating layer. In the preferred embodiment the protective coating layer is at least two layers and includes a durable coating layer and a resilient coating layer.
  • the protective coating layer is preferably comprised of a durable coating layer, such as a mixture of collodion and nylon and a resilient coating layer such as collodion.
  • the nylon is preferably selected from the group consisting of polycaprolactam, polylauryl-lactam and polyhexamethylene sebacamide.
  • the order of the protective layers can be either with the resilient layer coating the dual bacteriostatic/bactericidal antimicrobial layer and the durable layer coating the resilient layer or the reverse, i.e., the durable layer coating the antimicrobial layer and the resilient layer coating the durable layer.
  • the method for this coating technique is not limited to the examples provided in U.S. Pat. No. 5,756,145.
  • the treatment solution consists of a solvent of a saturated short chain monocarboxylic acid such as formic acid, acetic acid, and propionic acid with a liquidity state below 90° C. and above 10° C. and a pKa of 3 to 5.
  • the formic acid solution is 88% formic acid.
  • glycerol or glycerin is used as a plasticizer and a vehicle solvent. It also acts as a lubricant between polymer chains to prevent the polymer from becoming brittle during the treatment process.
  • the glycerol also forms hydrogen bonding with its hydroxyl groups [—OH] with the polymer as well as the antimicrobial agents during the treatment process facilitating the incorporation of coating agents (antimicrobial or non-antimicrobial) into the medical device.
  • the total volume of the resulting coating mixture can be composed of 79% formic acid solution (range between 10% to 90%), 8% ortho-phosphoric acid solution (range between 5% to 10%), and 13% glycerin (range between 8% to 15%).
  • the antimicrobial agents are added to the solution before addition of glycerin to avoid dissolution at a higher viscosity that glycerin adds to the coating solution.
  • any combination of the bacteriostatic and bactericidal agents can be used as long as the synergistic effect has been shown to be effective in reducing microbial colonization.
  • the device After the treatment period, the device is removed and shaken vigorously or purged with nitrogen gas to remove any excess solution from the device. The device is then placed under a well-ventilated fume hood for at least 16 hours (it is recommended to dry for 48 hours to insure removal of excess glycerin and formic acid). This drying step is optimally performed in the dark. After the drying period the device is rinsed and flushed with deionized water and placed back under the fume hood for another 10-24 hour period.
  • Another aspect to this invention is the application of the combination of bacteriostatic and bactericidal agents used for flushing catheters and other medical devices.
  • Microorganisms that attach themselves to inert surfaces produce a layer made of exopolysaccharide called microbial biofilm. These organisms embed themselves in this layer. This biofilm layer ultimately becomes the protective environment that shields these organisms on the inert surface from the antimicrobial activity of various antibiotics or antiseptics.
  • microbial biofilm a layer made of exopolysaccharide
  • biofilm penetrating agents combined with base materials can be used in order to effectively penetrate a biofilm composition successfully (U.S. Pat. No. 6,475,434, herein incorporated in its entirety as reference).
  • Suitable biofilm penetrating agents include the amino acid cysteine and cysteine derivatives.
  • cysteine L-cysteine, D-cysteine, DL-cysteine
  • DL-Homocysteine L-cysteine methyl ester
  • L-cysteine ethyl ester N-carbamoyl cysteine, cysteamine, N-(2-mercaptoisobutyryl)-L-cysteine, N-(2-mercaptopropionyl)-L-cysteine-A, N-(2-mercaptopropionyl)-L-cysteine-B, N-(3-mercaptopropionyl)-L-cysteine, L-cysteine ethyl ester hydrochloride, nacystelyn (a lysine salt of N-acetylcysteine), N-acetylcysteine, and derivatives thereof.
  • cysteine L-cysteine, D-cysteine, DL-cysteine
  • the biofilm penetrating agent is N-acetylcysteine and derivatives thereof (U.S. Pat. No. 6,475,434).
  • Other derivatives of N-acetylcysteine including esters, amides, anhydrides, and thio-esters and thio-esters of the sulfhydryl moeity, can be used as well as biofilm penetrating agents.
  • salts of N-acetylcysteine and derivatives of N-acetylcysteine may also be used as biofilm penetrating agents.
  • these salts include sodium salts, e.g., N-acetyl-L-cysteine sodium salt and N-acetyl-L-cysteine sodium zinc monohydrate, potassium salts, magnesium salts, e.g., N-acetyl-L-cysteine magnesium zinc salts, calcium salts, e.g., N-acetyl-L-cysteine calcium zinc monohydrate, zinc salts, e.g., N-acetyl-L-cysteine zinc salt, zinc mercaptide salts, ammonium slats, e.g., N-acetyl-L-cysteine ammonium zinc salt, calcium zinc N-acetyl-L-cysteinate acetate, zinc mercap
  • the biofilm penetrating agent is included in the biofilm penetrating composition in amounts sufficient to penetrate, or break-up the biofilm and provide the biofilm penetrating agent, antimicrobial agent, and/or antifungal agent access to the biofilm embedded microorganisms thereby facilitating the removal of substantially all of the biofilm embedded microorganisms from at least one surface of the medical device.
  • the biofilm penetrating agent may be 100% of the biofilm penetrating composition, preferably, the biofilm penetrating composition contains from at least about 0.01% to about 60% biofilm penetrating agent by weight based upon the total weight of the biofilm penetrating composition being employed.
  • the biofilm penetrating composition includes from at least about 0.5% to about 30% (by weight) biofilm penetrating agent (U.S. Pat. No. 6,475,434).
  • base material is defined herein as any of a group of materials which effectively disperses the biofilm penetrating agent at an effective concentration to penetrate, or break-up, the biofilm thereby facilitating access of the biofilm penetrating agent, antimicrobial agents, and/or antifungal agents to the microorganisms embedded in the biofilm, and thus, removal of substantially all of the microorganisms from at least one surface of the medical device.
  • base material also includes any group of solutions which effectively disperse the biofilm penetrating agent at an effective concentration to form a biofilm penetrating composition coating for medical devices which substantially prevents the growth or proliferation of biofilm embedded microorganisms on at least one surface of the medical device.
  • the base material also facilitates the adhesion of the biofilm penetrating composition to at least one surface of the medical device and prevents the biofilm penetrating composition coating from being easily removed from the surface of the medical device, thereby facilitating the utilization of the biofilm penetrating composition to coat at least one surface of a medical device (U.S. Pat. No. 6,475,434).
  • suitable base materials include, but are not limited to, buffer solutions, phosphate buffered saline, saline, water, polyvinyl, polyethylene, polyurethane, polypropylene, silicone (e.g., silicone elastomers and silicone adhesives), polycarboxylic acids, (e.g., polyacrylic acid, polymethacrylic acid, polymaleic acid, poly-(maleic acid monoester), polyaspartic acid, polyglutamic acid, aginic acid or pectimic acid), polycarboxylic acid anhydrides (e.g., polymaleic anhydride, polymethacrylic anhydride or polyacrylic acid anhydride), polyamines, polyamine ions (e.g., polyethylene imine, polyvinylarnine, polylysine, poly-(dialkylamineoethyl methacrylate), poly-(dialkylaminomethyl styrene) or poly-(vinylpyridine)), polyammonium ions
  • biofilm penetrating composition may include any number of biofilm penetrating agents and base materials, in the case of internal or external use of the biofilm penetrating composition with humans or animals, the biofilm penetrating agent and base material should be biocompatible with the human beings or animals in which the medical device is inserted or implanted.
  • Biocompatible is herein defined as compatible with living tissues, such that the medical device is not rejected or does not cause harm to the living tissue (U.S. Pat. No. 6,475,434).
  • a further embodiment of this invention is to use the bacteriostatic/bactericidal combination as a flushing agent (with combinations of at least one chelator/anticoagulant in a preparation in alcohol) that allows rapid reduction and/or eradication of microorganisms embedded in a biofilm in a time as short as about 15 minutes.
  • a number of exemplary chelating agents, in combination with bacteriostatic/bactericidal agents, can be used in the flushing of a medical device include, but are not limited to, EDTA, EGTA, EDTA 2Na, EDTA 3Na, EDTA 4Na, EDTA 2K, EDTA 2Li, EDTA 2NH4, EDTA 3K, Ba(II)-EDTA, Ca(II)-EDTA, Co(II)-EDTA, Cu(II)-EDTA, Dy(III)-EDTA, Eu(III)-EDTA, Fe(III)-EDTA, In(III)-EDTA, La(III)-EDTA, CyDTA, DHEG, diethylenetriamine penta acetic acid (DTPA), DTPA-OH, EDDA, EDDP, EDDPO, EDTA-OH, EDTPO, EGTA, HBED, HDTA, HIDA, IDA, Methyl-EDTA, NTA, N
  • the lock-in solution used to flush medical devices contains an effective concentration of bacteriostatic and bactericidal agents that act in synergy in order to enhance the efficacy of the lock-in solution.
  • the flushing solution of the present invention may or may not require an anticoagulant and/or a chelator. It is further contemplated that the flushing solution of the present invention can be left to wash over the medical device between 15 minutes to 4 hours, or any time between in order for the solution to effectively eliminate further colonization and to break up established biofilm layers on the medical device. It is envisaged that the unique combination of a bacteriostatic and bactericidal agents in this solution can in fact be more effective in preventing, abrogating, and reducing microbial colonization on medical devices than a single agent alone.
  • kits comprising compositions to coat or flush the surfaces of medical devices prior to implantation into a mammal comprising two different antimicrobial agents, a bacteriostatic and a bactericidal.
  • the kit will be packaged for commercial use of coating medical devices or it will be contained as a package for flushing
  • a further embodiment of this invention is a kit comprising of a solution containing the bactericidal and bacteriostatic agents in an effective concentration to reduce colonization of microbial organisms when used to coat and/or flush medical devices.
  • a solution containing the bactericidal and bacteriostatic agents in an effective concentration to reduce colonization of microbial organisms when used to coat and/or flush medical devices.
  • the kit will optionally include an instruction sheet insert to identify how the kit is to be used.
  • kits described in this section are exemplified by a solution comprising of a bacteriostatic and bactericidal agent, preferably a tetracycline and an aminoglycoside based drug, as the antibiotic, EDTA as the chelator/anticoagulant, and ethanol.
  • a bacteriostatic and bactericidal agent preferably a tetracycline and an aminoglycoside based drug
  • antibiotic EDTA
  • chelator/anticoagulant EDTA
  • ethanol chelator/anticoagulant
  • any other combination of one or more antibiotic, one or more chelator/anticoagulant, and ethanol as described in the present disclosure may be packaged in a similar manner.
  • the kit may comprise of one or two or three or more compartments.
  • the components of the kit may be provided in separate compartments or in the same compartment.
  • the components of the kit may be provided separately or mixed.
  • the mixed components may contain two or more agents such as an antibiotic, a chelator/anticoagulant
  • One of the packaging options below maintain the ingredients, for example, the antibiotic and the chelating agent/anticoagulant, for example EDTA, in an uncombined form. These components are to be combined shortly before use. These packaging options are contemplated to be part of a 2-compartment or three-compartment container system to provide a total volume of about 3 ml of the ready to use preparation. Any compartmentalized container system may be used to package the compositions of the present invention.
  • the options outlined below are envisaged to be non-limiting examples of how the lock/flush solution described herein can be packaged, compartmentalized, and commercialized.
  • kits may include a container means comprising a volume of diluent, comprising an alcohol optionally diluted if required in a solution such as saline or sterile water, a second (or more) container means comprising one or more antimicrobial or biocide, a third (or more) container means comprising one or more chelating/anticoagulant agent.
  • a container means comprising a volume of diluent, comprising an alcohol optionally diluted if required in a solution such as saline or sterile water
  • a second (or more) container means comprising one or more antimicrobial or biocide
  • a third (or more) container means comprising one or more chelating/anticoagulant agent.
  • the dry components may optionally be mixed in one compartment.
  • the addition of the diluent would then be performed immediately prior to use.
  • the container means of the kits will generally include at least one vial, test tube, flask, bottle, syringe or other container means, into which the antimicrobial/chelator/anticoagulant/alcohol may be placed, and preferably, suitably aliquoted. Where a second or third antibiotic agent, other chelator, alcohol, or additional component is provided, the kit will also generally contain a second, third or other additional container into which this component may be placed.
  • the kits of the present invention will also typically include a means for containing the alcohol, antimicrobial agent, chelator/anticoagulant, and any other reagent containers in close confinement for commercial sale. Such containers may include injection or blow-molded plastic, or glass containers into which the desired vials are retained.
  • the present invention utilizes a combination of typically considered antagonistic agents, bacteriostatic and bactericidal agents, to achieve inhibition of microbial growth or colonization.
  • the inhibition can be synergistically or additively.
  • the references included herein in their entirety, Rahal (1978), Lepper and Dowling (1951), Strausbaugh and Sande (1978), Rahal et al. (1974), and McCabe et al. (1965) describe the apparent antagonisms between certain bacteriostatic and bactericidal drugs when used in combination systemically. Despite these apparent published antagonisms, the present invention demonstrates a unique pharmaceutical combination of the two disparate antimicrobial agents on medical devices that, when used in an effective concentration, reduce microbial colonization.
  • the combination of antimicrobial agents comprise an aminoglycoside based drug in combination with a tetracycline based drug.
  • minocycline a tetracycline
  • tobramycin an aminoglycoside
  • this unique combination of a bactericidal agent with a bacteriostatic agent is more effective at bacterial reduction than when a single bactericidal or bacteriostatic agent is solely used topically.
  • This unique combination is further demonstrated by the theoretically antagonistic interaction between bacteriostatic and bactericidal agents when given through an oral administration or systemically.
  • the mechanisms of action for both bactericidal and bacteriostatic drugs are antagonistic since both bind to the 30S subunit of ribosomes in order to eliminate the pathogen.
  • Solubility antagonisms exist as well, since aminoglycosides are very soluble in water but not in organic solvents, while tetracyclines are very soluble in organic solvents; in this invention, however, both are successfully dissolved in an organic acid, formic acid.
  • aminoglycosides have not empirically been used for prevention of device-related infections, while tetracyclines have been shown to systemically reduce the antimicrobial activity of aminoglycosides. The synergism between these two classes is inconceivable for all the aforementioned reasons, yet in the unique application of the present invention, there is marked enhanced antimicrobial effect as shown below in the examples.
  • bactericidal-bacteriostatic combinations that can be used in the present invention include (a) aminoglycosides-Sulfonamides (includes sulfadiazine, sulfisoxazole, sulphafurazole, sulfamethoxazole, sulfamethizole, sulfadimidine, sulfacarbamide, sulfadoxine, sulgaguanidine, sulfathalidine, sulfasalazinesulfamylon) and (b) aminoglycosides-trimethoprim and/or (c) aminoglycosides-clindomycin/lincocomycin
  • bacteriaicidal agents that can be used in the present include those from the group consisting of aminoglycosides, penicillins, cephalosporins, carbapenems, glycopeptides, rifamycins, fusidic acid, sulfonamides, streptogramins, and lipopeptides.
  • Bacteriostatic antibiotics include those from the group consisting of tetracyclines, macrolides, ketolides, oxazolidinones, and lincosamindes.
  • bactericidal agents include, but are not limited to, kanamycin, gentamicin, tobramycin, netilmicin, sisomicin, amikacin, ampicillin, amoxicillin, cloxacillin, dicloxacillin, ticarcillin, indanyl carbenicillin, azlocillin, mezlocillin, nafcillin, oxacillin, piperacillin, cefazolin, cephalothin, cephapirin, cephradine, cefamandole, cefonicid, cefuroxime, cefmetazole, cefotetan, cefoxitin, cefotaxime, cefoperazone, ceftazidine, ceftizoxime, ceftriaxone, moxalactam, cefepime, cefpirome, cefadroxil, cephalexin, cephradine, cefaclor, cefprozil, cefuroxi
  • bacteriostatic agents include, but are not limited to, erythromycin, clarithromycin, azithromycin, spiramycin, telithromycin, chloramphenicol, linezolid, eperezolid, clindamycin, and lincomycin.
  • the present invention is utilized to markedly inhibit, reduce, prevent, abrogate, or minimize bacterial colonization by coating medical devices with a bacteriostatic and bactericidal agent, or to flush the medical device in order to achieve the latter stated results.
  • Reduction, abrogation, minimization or prevention of microbial growth can be attributed to the combination of the bacteriostatic and bacteriocidal agents acting synergistically and/or additively when used in an effective concentration such that the concentration is effective to reduce the growth of colonization of the microbes by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100% or any range therebetween.
  • Gram-negative bacteria classified by the Gram stain as having a red stain, have thin walled cell membranes consisting of a single layer of peptidoglycan and an outer layer of lipopolysacchacide, lipoprotein, and phospholipid.
  • Exemplary organisms include, but are not limited to, Enterobacteriacea consisting of Escherichia, Shigella, Edwardsiella, Salmonella, Citrobacter, Klebsiella, Enterobacter, Hafnia, Serratia, Proteus, Morganella, Providencia, Yersinia, Erwinia, Buttlauxella, Cedecea, Ewingella, Kluyvera, Tatumella and Rahnella.
  • exemplary gram-negative organisms not in the family Enterobacteriacea include, but are not limited to, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia, Cepacia, Gardenerella, Vaginalis, and Acinetobacter species.
  • Gram-positive bacteria classified using the Gram stain as having a blue stain, have a thick cell membrane consisting of multiple layers of peptidoglycan and an outside layer of teichoic acid.
  • Exemplary organisms include, but are not limited to, Staphylococcus aureus, coagulase-negative staphylococci, streptococci, enterococci, corynebacteria, and Bacillus species.
  • the device used in this example is a composite hernia patch with polypropylene mesh on one side and polytetrafluoroethylene (PTFE) on the other side.
  • Antibiotics were incorporated onto devices by using a patented method (U.S. Pat. No. 6,589,591) that utilized coating solutions that contained 100 mg/ml of minocycline; 100 mg/ml tobramycin; 100 mg/ml gentamicin; 100 mg/ml minocycline and 100 mg/ml tobramycin (minocycline dissolved first); or 100 mg/ml minocycline and 100 mg/ml gentamicin (minocycline dissolved first).
  • the tested square device segments were 10 mm (long) ⁇ 10 mm (wide) ⁇ 2 mm (thick).
  • the device segments were placed onto agar with their long axis perpendicular to the agar (i.e. only 2 mm of the segment was in contact with the agar). All zone of inhibition are expressed in mm, and table 1 summarizes the results of the zones of inhibition.
  • TABLE 1 Enterococcus Staphyulococcus faecalis aureus Escherichia coli Treatment (gram positive) (gram positive) (gram negative) Minocycline 3 11 3 Tobramycin 9 12 18 Gentamicin 0 14 11 Minocycline & 14 14 20 Tobramycin Minocycline & 8 19 21 Gentamicin
  • the device used in this example is a 7-french, polyurethane central venous catheter.
  • Antibiotics were incorporated onto devices by using a patented method (U.S. Pat. No. 6,589,591) that utilized coating solutions that contained 100 mg/ml of minocycline; 100 mg/ml tobramycin; 100 mg/ml gentamicin; 100 mg/ml minocycline and 100 mg/ml tobramycin (minocycline dissolved first); or 100 mg/ml minocycline and 100 mg/ml gentamicin (minocycline dissolved first).
  • the tested catheter segments were 10 mm (long) ⁇ 2 mm (wide).

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